Electronic Prior Auth Management
Initiate ePA
Locate the medication in the patient’s Pending Medications list. From the Actions dropdown, click “Start Prior Auth”:
A pop up will open with the option to either complete the PA process electronically or offline. Click “ePA Request” to send a PA initiation request to the Payer. The medication will move from the Pending Medications list to the Active Prior Authorization Requests section. Checking the “Expedite Prior Authorization” button for an ePA Request will send an expedited request to the Payer for that PA request, and it will move to the Active Prior Authorization Requests section.
Active Prior Authorization Requests
The Active PA Requests section displays a list of the patient’s PA requests that are currently in progress. Here, any clinical staff can review prescription details, PA status, and notes. The Status icon shows the current PA request status.
To view more details, click on the status icon to open the Prior Authorization Prescription Log:
Prior Auth requests may include an Expected Response date.
Potential Status Icons
Prior Authorization Questions
Before approving a PA request, the Payer can request for additional information from the clinician. This is indicated by the “Action Required” status icon. From the Actions dropdown, click “Answer Questions” to open the PA question workflow.
Complete the question set. Review all answers in the Question Set Summary, and click “Submit” to send the information to the Payer. A pop up will appear to confirm the submit. Click “OK”.
ePA Approval
If a PA request is approved by the Payer, the prescription will be moved to the patient’s Pending Medications list. The clinician can then approve and send the prescription to the pharmacy or approve and print the prescription.
To view the Prior Authorization history of a medication, click “View Prior Auth History” in the Medication column. This section displays the Final Status, Authorization #, Status Logs, Question Sets (if applicable), and Appeal Note (if applicable).
Appeal
If a PA request was denied by the Payer, the clinician can request for an appeal (if available) The Appeal Note in the Prior Authorization History section will state whether or not the denial can be appealed:
In the Pending Medications list, select “Appeal Prior Auth” from the Actions drop down. In the PA Appeal popup, enter a comment for the appeal, and click Submit to send the appeal request to the Payer. The prescription will be moved from the patient’s Pending Medications list to the Active Prior Authorization Requests section.
The Payer can request for additional information from the clinician for the appeal request. Submit the information through completing the question workflow. If the PA request is approved, the prescription will be moved back to the patient’s Pending Medications list, and the clinician can send the prescription to the pharmacy.
Partial Denial
A PA request may be partially denied by the Payer. Clinicians may deny the request, make changes to the request, or cancel the request.
Denying the request accepts the denial from the Payer. Cancel and Restart cancels the Prior Authorization request and brings the clinician to step 3 of the Add Prescription process (with the prescription populated) for the Clinician to make any necessary changes and resend as a new prescription.